A nurse is caring for a client after tonsillectomy and adenoidectomy. The nurse
notes that the client has become restless and is swallowing frequently.
... [Show More] List in
order of priority the actions that the nurse should take in this situation, with
number 1 as the first action.
Correct
A. Inspecting the client’s throat
B. Checking the client’s vital signs
C. Notifying the surgeon
D. Maintaining NPO status
Rationale: Bleeding is a potential complication after tonsillectomy and
adenoidectomy. If the client becomes restless and is swallowing frequently, the
nurse should suspect bleeding. The nurse would first inspect the throat for the
presence of bleeding and then check the client’s vital signs for indications of
hypovolemia. The surgeon would be notified. Because recauterization is the
treatment of choice when bleeding is uncontrolled, the client would be
maintained on nothing-by-mouth (NPO) status in anticipation of a return to
surgery.
Test-Taking Strategy: Focus on the data in the question and use your prioritizing
skills. Noting the strategic words “swallowing frequently” will direct you to
assessment of the client for bleeding as the first action. The next step is
checking the vital signs next to detect signs of shock and to have the data that
the health care provider will need. Although food or fluids would not be given to
the client during this episode anyway, keeping the client on NPO status would
be the fourth priority. Review the nursing actions to be taken immediately when
bleeding occurs after tonsillectomy and adenoidectomy if you had difficulty with
this question.
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Perfusion
HESI Concepts: Collaboration/Managing Care – Care Coordination,
Perfusion/Clotting
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 644). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
12.ID: 9476876993
A nurse is caring for a client with a diagnosis of endocarditis when the client
suddenly begins to experience chest pain, dyspnea, and tachypnea. The nurse
suspects that the client has a pulmonary embolism. List in order of priority the
actions that the nurse would take in this situation, with number 1 as the first
action.
Correct
A. Placing a nasal oxygen cannula on the client
B. Notifying the health care provider
C. Ensuring that the intravenous (IV) line is patent
D. Preparing an IV heparin sodium infusion
E. Preparing the client for a computerized tomography (CT) scan
Rationale: Pulmonary embolism is a life-threatening emergency. Stabilizing the
cardiopulmonary system is the first priority. Nasal oxygen is administered
immediately to relieve hypoxemia, respiratory distress, and central cyanosis.
The health care provider is notified. Because IV infusion lines are needed to
administer fluids to treat the hypotension and to administer medications, the
nurse ensures that the client has patent IV lines. Anticipating that IV
anticoagulant therapy will be started, the nurse next prepares an administration
set. Finally, because a CT scan or other diagnostic test may be performed to
confirm the diagnosis, client preparations for testing are begun.
Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of
prioritizing. Recalling that stabilizing the cardiopulmonary system is the priority
will direct you to the administration of oxygen. Recognizing the immediacy of
the situation will then direct you to notification of the health care provider. Next,
visualize the situation to determine the order of the remaining options. Review
the nursing actions to be taken immediately in the event of pulmonary embolism
if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Perfusion
HESI Concepts: Collaboration/Managing Care – Care Coordination,
Perfusion/Clotting
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems
(9th ed., p. 552). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
13.ID: 9476867298
A client is brought to the emergency department after a motor vehicle crash in
which the client sustained a blunt chest injury when his chest struck the steering
wheel. The client is complaining of sharp pain on inspiration and dyspnea. The
nurse notes the absence of breath sounds on the affected side. The nurse
would immediately:
A. Obtain a chest x-ray
B. Notify the health care provider
C. Place the client in a semi-Fowler position Correct
D. Prepare a thoracentesis tray and chest drainage equipment
Rationale: The client is exhibiting signs of a closed pneumothorax. If a closed
chest injury is suspected, the nurse must immediately place the client in a semiFowler position. Because this is a medical emergency, the nurse then notifies
the health care provider. A chest x-ray, computed tomography, or
ultrasonography would be used to confirm the diagnosis of pneumothorax.
Because treatment involves thoracentesis and placement of a chest drainage
system, the nurse then prepares a thoracentesis tray and chest drainage
equipment.
Test-Taking Strategy: Analyze the information in the question to determine that
the client has a closed pneumothorax. From this point use your knowledge of
the ABCs (airway, breathing, and circulation) to identify the correct initial option.
An upright position will help the client breathe. Review the nursing actions to be
taken immediately in the event of a closed pneumothorax if you had difficulty
with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/PrioritizingGiddens Concepts: Care Coordination,
Gas Exchange
HESI Concepts: Collaboration/Managing Care – Care Coordination,
Oxygenation/Gas Exchange
Reference: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of
Emergency Care (7th ed., p. 415). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
14.ID: 9476864343
A registered nurse (RN) is planning assignments for six clients on a nursing
unit. The RN has an RN, a licensed practical nurse (LPN), and an unlicensed
assistive personnel (UAP) on the nursing team. Which clients should the nurse
assign to the RN? Select all that apply
A. A client who requires tap water enemas until clear
B. A client with newly diagnosed type 1 diabetes mellitus Correct
C. A client requiring complete assistance with personal care
D. A client with gastrointestinal bleeding and a hemoglobin of 7.3
mg/dL (73 g/L)
E. Correct
F. A client who was admitted during the night after an acute asthma
attack Correct
G. A client who has undergone amputation of the right leg amputation
and a dressing change
Rationale: When delegating nursing assignments, the nurse must consider the
skills and educational level of the nursing staff. The client with newly diagnosed
type 1 diabetes mellitus will require significant education, which should be
provided by the RN. The client with gastrointestinal bleeding and a low
hemoglobin level will likely require a blood transfusion, which must be
performed by the RN. The client who was admitted to the hospital during the
night after an acute asthma attack would most appropriately be assigned to the
RN, because frequent respiratory assessments will be required. The UAP can
most appropriately assist with personal care. The LPN can perform dressing
changes and administer enemas.
Test-Taking Strategy: Recall that education and job position, as set forth in the
state’s nurse practice act, and employee guidelines must be considered when
activities are being delegated and assignments made. Recall that the RN has
the knowledge and experience to perform client education, nursing
assessments, and blood transfusions. If you had difficulty with this question,
review the principles of delegation and assignment-making.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/PrioritizingGiddens Concepts: Care Coordination,
Safety
HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety
Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and
trends (8th ed., pp. 305, 308). St. Louis: Elsevier
Awarded 3.0 points out of 3.0 possible points.
15.ID: 9476879575
A registered nurse (RN) is planning the client assignments for the day. To which
nurse does the RN appropriately assign care of a woman undergoing
brachytherapy with a sealed radiation source for cervical cancer?
A. A pregnant nurse who has special expertise in oncology
B. A nurse who has worked with clients undergoing brachytherapy in
the past Correct
C. A male nurse who has never worked with a client undergoing
brachytherapy
D. A nurse who is also assigned to provide care to another client
undergoing brachytherapy
Rationale: Brachytherapy involves the use of radioactive isotopes in solid form
or within body fluids. Because the radiation source is within the client, the client
emits radiation for some time and may pose a hazard to others. A pregnant
nurse should not care for a client undergoing brachytherapy. The time any
nurse is exposed to such radiation sources should be limited to 30 minutes of
direct care per 8-hour shift, so a nurse should not be assigned to care for more
than one client undergoing brachytherapy. It is most appropriate to assign a
nurse who is familiar with the care of a client with brachytherapy rather than to
assign a nurse who is not.
Test-Taking Strategy: Use the process of elimination. Recalling the radiation
safety standards involved in the care of a client undergoing brachytherapy will
assist you in eliminating the pregnant nurse and the nurse caring for another
client undergoing brachytherapy. From the remaining options, note the strategic
word “appropriately.” It is appropriate to assign a nurse who is familiar with the
care of a client with brachytherapy instead of one who is not. Review radiation
safety standards for the care of a client undergoing brachytherapy if you had
difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/PrioritizingGiddens Concepts: Care Coordination,
Safety
HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 413). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
16.ID: 9476864326
A client is complaining of chest pain, and the nurse notes that the client’s skin is
cool and clammy. The client is receiving oxygen at a rate of 2 L/min, and the
pulse oximetry reading is 84%. Which action should the nurse take first?
A. Administering nitroglycerin
B. Taking the client’s vital signs
C. Increasing the oxygen to 3 L/min Correct
D. Obtaining an arterial blood gas (ABG) specimen
Rationale: Pulse oximetry identifies hemoglobin saturation. A pulse oximetry
reading can alert the nurse to desaturation before clinical signs occur. Ideal
pulse oximetry values range from 90% to 100%. A range of 85% to 89% is
acceptable in certain chronic disease conditions. When the value is below 85%,
the body’s tissues have a difficult time becoming oxygenated. Therefore the
nurse would increase the oxygen to 3 L/min. Although the client is complaining
of chest pain, there is no information to indicate that the client is experiencing
chest pain that is cardiac in origin, so administering nitroglycerin as the first
action is incorrect. Taking the client’s vital signs and obtaining an ABG
specimen will provide additional data, but in this situation an intervention is
needed first.
Test-Taking Strategy: Note the strategic word “first.” Use the process of
elimination and your knowledge of the ABCs (airway, breathing, and circulation).
This will direct you to the correct option. Review pulse oximetry values and
appropriate interventions if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/PrioritizingGiddens Concepts: Care Coordination,
Gas Exchange
HESI Concepts: Collaboration/Managing Care – Care Coordination,
Oxygenation/Gas Exchange
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 589, 750). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
17.ID: 9476878102
A nurse is assigned to care for a client with a closed chest drainage system that
was inserted 1 day ago after the client sustained a stab wound to the chest. List
in order of priority the actions that the nurse would take in caring for the client,
with number 1 the first action.
Correct
A. Assessing patency and function of the chest tube
B. Checking the client’s vital signs
C. Assessing the client’s level of discomfort
D. Asking the client to cough and deep-breathe
Rationale: The first action the nurse needs to perform is to assess the chest
tube’s patency and function, because a properly functioning chest drainage
system promotes adequate drainage of blood and air. After this assessment, the
nurse would check the client’s vital signs, including pulse oximetry. The nurse
would determine the client’s level of discomfort, then provide appropriate pain
relief measures, because improving the client’s level of comfort will facilitate
more effective coughing and deep-breathing efforts. Finally, the nurse would
encourage the client to cough and deep-breathe.
Test-Taking Strategy: Focus on the client’s problem. Use your knowledge of the
ABCs (airway, breathing, and circulation) to select assessment of chest tube
patency and function, then a check of the client’s vital signs. To select from the
remaining options, focus on effective means of facilitating coughing and deep
breathing. Review care of the client with a chest drainage system if you had
difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Gas Exchange
HESI Concepts: Collaboration/Managing Care – Care Coordination,
Oxygenation/Gas Exchange
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems
(9th ed., p. 546). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
18.ID: 9476876931
An emergency department (ED) nurse receives a telephone call and is informed
that several victims from a train accident will be brought to the ED. The nurse
who received the telephone call must first:
A. Activate the agency disaster plan Correct
B. Empty all available rooms in the ED
C. Ensure that the triage rooms are stocked with additional dressing
supplies
D. Call the intensive care unit (ICU) and asks for nurses to assist with
the victims
Rationale: In an external disaster, many people may be brought to an ED for
treatment. Calling the ICU and asking the nurses to assist with the victims,
making room for the arriving victims, and ensuring that making sure the triage
rooms are supplied may all be components of preparing for the casualties, but
activation of the disaster plan must be the initial action. Ideally the nurse would
notify the nursing supervisor, who would then ensure that the ED is adequately
staffed.
Test-Taking Strategy: Note the strategic word “first” in the query of the question.
Use the process of elimination in determining the priority action and also note
that the correct option is the umbrella option. Once you activate the disaster
plan, the activities in the other options will be carried out. Review procedures for
management in a disaster if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Disasters
Giddens Concepts: Care Coordination, Health Policy
HESI Concepts: Collaboration/Managing Care – Care Coordination, Health
Policy/Systems – Health Care Organization
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., pp. 160-161). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
19.ID: 9476880352
A home health nurse is assigned to three client visits today. One client requires
twice-daily irrigation of an abdominal wound. Another client was discharged
from the hospital yesterday after cardiac catheterization and will require an
admission assessment and assistance with the scheduling of medications. The
last client has diabetes mellitus and requires a blood specimen for serum
glucose testing to be drawn. The nurse will schedule the assignment by visiting:
A. The client with diabetes mellitus first, the client with the wound
irrigation second, and the client requiring admission last Correct
B. The client needing wound irrigation first, the client with diabetes
mellitus second, and the client requiring admission last
C. The client requiring admission first, the client with diabetes mellitus
second, and the client needing wound irrigation last
D. The client with diabetes mellitus first, the client requiring admission
second, and the client needing wound irrigation last
Rationale: The client with diabetes mellitus must remain on nothing-by-mouth
(NPO) status until the blood specimen is drawn and so should be seen first.
Because the client requiring wound irrigations will need to be visited twice, that
client should be seen next. The client requiring admission would be visited third,
after which the nurse would make the second visit to the client requiring wound
irrigation.
Test-Taking Strategy: Think about the needs of each client in determining the
correct option. The client who must remain NPO until visited by the nurse is the
priority. Because the wound irrigation must be performed twice, the two visits
should be separated by as much time as possible, so this client would be the
next and then visited last. The admission assessment may take some time to
complete, so this client would be visited third. If you had difficulty with this
question, review time management and prioritization of client needs.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical Decision-Making/Clinical Judgment,
Collaboration/Managing Care – Care Coordination
References: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013).
Fundamentals of nursing. (8thed., pp. 20, 237). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
20.ID: 9476871009
A registered nurse is planning client assignments for the day. Which clients
should the nurse assign to the unlicensed assistive personnel (UAP)? Select all
that apply.
A. A client scheduled for colonoscopy Incorrect
B. A client who underwent mastectomy 2 days ago
C. A client scheduled for discharge after cardiac catheterization
D. A client with diarrhea who requires assistance with hygiene care
Correct
E. A client on strict bed rest who requires range-of-motion exercises
every 2 hours Correct
Rationale: The registered nurse is legally responsible for client assignments and
must assign tasks on the basis of the guidelines of the nurse practice act and
the job description of the employing agency. A client scheduled for colonoscopy
has physiological needs and requires nursing assessments, as well as
psychosocial support. A client who underwent mastectomy 2 days earlier will
require both physiological and psychosocial care. A client scheduled for
discharge after cardiac catheterization will require reinforcement of medication
information and home care management. The nursing assistant may care for
the client requiring hygiene care for diarrhea. The UAP has been trained to care
for a client on bed rest and in the procedure for performing range-of-motion
exercises. The nurse would provide instructions to the UAP regarding these
tasks, but the tasks required for this client are within the role description of a
UAP.
Test-Taking Strategy: Note that the question asks for the assignment to be
delegated to the UAP. When asked questions related to delegation, think about
the role description of the employee and the needs of the client. Remember that
tasks that are noninvasive and basic may safely be assigned to the UAP. In
using the process of elimination, you will easily identify the correct options.
Review the responsibilities of delegation if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Giddens Concepts: Care Coordination, Health Care Policy
HESI Concepts: Collaboration/Managing Care – Care Coordination, Health
Policy/Systems – Health Care Organization
Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and
trends (8th ed., p. 305). St. Louis: Elsevier [Show Less]